Expanding your Dental Practice to Meet the Oral Health ... · patient to be transported to the dentist's office. SAME AS FEDERAL 3. An advisory dentist shall provide consultation,

Expanding your Dental Practice to Meet the Oral Health Needs of

Residents in Long Term Care Facilities

Kentucky Dental Association

Annual Session 2014

Pam Stein DMD, MPH

Objectives

• Demographics, Trends and Definitions

• Consent and legal considerations

• Documenting and billing for dental care in long term care

• Working effectively with leadership and nursing staff

• Effective communication and patient management strategies

Why talk about Long-Term Care?

Percent of US Population in Selected Age Groups, 1970-2050

Source US Census Bureau and Jacobsen, Kent, Lee, Mather, America’s Aging Population, Population Reference Bureau, 2011, Vol .66, No 1.

2012 National Population Projections US Census Bureau

85 and older fastest growing

Light grey Less than 13% Peach 13% to 15% Dark Grey 16% to 19%Rust 20%+

U.S. Census Bureau, 2009 Population Estimates

Life Expectancy

Women 81.1

Men 76.3

Source: National Vital Statistic Reports 2012

Survivorship Effect

Life expectancy at age 65

Women = additional 20.3 years (85.3 vs 81.1)

Men = additional 17.7 years (82.7 vs. 76.3)

http://www.cdc.gov/nchs/data/hus/hus12.pdf#018

Survivorship Effect

Life expectancy at age 75

Women= additional 12.9 years (87.9 vs 81.1)

Men = additional 11 years (86 years vs 76.3)

http://www.cdc.gov/nchs/data/hus/hus12.pdf#018

• In the 1950’s half of all Americans over age 65 had lost all of their natural teeth.

• In 2008, 18% of adults over age 65 had no remaining teeth.

Living Longer and Keeping Teeth

National Oral Health Surveillance System 2008 http://apps.nccd.cdc.gov/nohss/ListV.asp

Fewer dentures and more teeth!

In 1999, 44.3% of 65 + in KY edentulous

In 2008, 23.7% of 65 + in KY edentulous

From Oral Health Resources, National Center for Chronic Disease Prevention and health PromotionAt http://apps.nccd.cdc.gov/nohss/ListV.asp?qkey=8&DataSet=2

Where are adults 65 + living?

The 5% Fallacy

Only 5% of 65+ Americans reside in nursing homes at any point in time

BUT….

Nearly half of Americans 65 and older will spend time in a nursing home at some time in their lives.

15% of 85 and older live in Nursing Homes at any given time

85 and older fastest growing

Dentists can expect to be in more demand in nursing homes

Heightened awareness of lack of care in NH2013 NYT article

Increase in % of nursing homes surveyed that received a deficiency in dental services.

Office of Inspector General Analysis of OSCAR data, 2008 available at http://oig.hhs.gov/oei/reports/oei-02-08-00140.pdf

If a nursing home calls you and asks you to be provide dental services what

would you ask?

Request a face to face meeting

What they want from you?

• What services do they want you to provide?

• Your office or their facility?

• Expectations of you, availability ect?

• For how many patients?

• Documentation needed from you for services?

What you need to know about them.

• How their facility organized?

• Who is the medical director?

• Staffing ratios?

• What are their priorities? Oral hygiene?

• Will they send an aid to your office to help with patient?

• Who will you communicate with?

• Who is responsible liability wise?

• How you will handle HIPAA? Share information

Dentists should have a formal contract that outlines the

preceding details.

*Should consult with Attorney

Contract Discussion Point Nursing Home Dental Liaison

Your contact person on the “inside” (NH employee).

• Social worker

• Nurse

This person is KEY to reducing your stress and helping things go smoothly

How a Nursing Home Dental Liaison Helps You

• Assists in scheduling (knows best time for pt)

• Confirms appointments

• Handles transportation and CNA assignment if needed

• Get you the forms you need

• Make sure pre-meds are taken if needed

• Confirms space availability for in-service and tx

Another Contract Discussion PointDental Director Fee

• This is a payment to dentist from the long term care facility

• Usually an annual fee based on the number of residents

Dental Director Fee

• This is in addition to amount dentist is paid by Medicaid, Insurance or resident for dental treatment.

• Offsets cost of treating Medicaid patients, taking extra time to manage complex patients.

Dental Director Fee

• Estimated 60% utilization of dental services by residents

• If 100 residents, project 60 will come to dentist three times a year.

• 60 X 3 = 180 dental visits per year at the facility

• How much subsidy do you require per visit?

• 180 X $20 = $3600 per year director fee

Some facilities will also pay additional fee for ancillary services

- Taking emergency call

- Providing In-Service for staff

- Attorney fees for contract

- Consultation with facility regarding surveys

- Providing documentation of dental care provided

Must know the regulations

What are the federal and state mandates?

Omnibus Budget Reconciliation Act (OBRA) regulations are FEDERAL

Apply to facilities that accept Medicaid or Medicare

OBRA mandates facilities

• Provide or obtain from an outside resource routine and emergency dental services to meet the needs of each resident.

• Assist in making appointments and provide transportation

• Promptly refer residents with lost or broken dentures to a dentist

483.55 in Volume 42 Code of Federal Regulations (CFR)

Kentucky regulationswww.hpm.umn.edu/nhregsPlus/

1. Patients shall be assisted to obtain regular and emergency dental care. SAME AS FEDERAL

2. The facility, when necessary, shall arrange for the patient to be transported to the dentist's office. SAME AS FEDERAL

3. An advisory dentist shall provide consultation, participate in in-service education, recommend policies concerning oral hygiene, and shall be available in case of emergency.

4. Nursing personnel shall assist the patient to carry out the dentist's recommendations.

http://www.hpm.umn.edu/nhregsPlus/


Medical records shall include reports of dental services.



The facility shall conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity.

Assessment shall include dental assessment.

Source: 902 KAR 20:300


These assessments can be very informative for the dentist

• Behavior Assessment

• Cognitive Assessment

• Functional Assessment – can they transfer?

• Dental Assessment

Dental Professionals DO NOT do MDS oral assessment

MDS is done by nurses at the facility

A 30 minute training session by a dentist significantly improved nurses ability to correctly assess oral health status and treatment need.

Arvidson-Bufano et al. Nurses' oral health assessments of nursing home residents pre- and post-training: A pilot study. Special Care in Dentistry 1996;16:58-64

Current Minimum Data Set Requirements for Oral Health Assessment

1. Debris present in the mouth prior to going to bed

2. Has dentures or removable bridge

3. Some/all natural teeth lost—does not have or does not use dentures (or partial plates)

4. Broken, loose, or carious teeth

5. Inflamed gums (gingiva); swollen or bleeding gums; oral abscesses; ulcers or rashes

6. Daily cleaning of teeth/dentures or daily mouth care by resident or staff.

Guay A, The oral health status of nursing home residents: what do we need to knowJ Dent Education 2005;69:1015-1017

ADA and Special Care in Dentistry have suggested MDS revisions:

1. Chewing problems or mouth/facial pain or discomfort

2. Abnormal mouth tissue (ulcers, masses, oral lesions)

3. Problem with a denture or partial denture

4. Natural teeth or tooth fragments

5. Obvious cavity(s) or broken tooth (teeth)

6. A loose natural tooth (teeth)

7. Inflamed or bleeding gums.

Guay A, The oral health status of nursing home residents: what do we need to knowJ Dent Education 2005;69:1015-1017

MDS is supposed to act as trigger for action

Is it a trigger for action in a patient with oral problems?

Are the oral problems even recorded because then it would require some action?

2010 JADA paper deals with oral neglect in institutionalized elders

“the absence of a consensus definition of oral neglect means that there can be no systematic enforcement of this legislative mandate.”

Katz et al. Defining oral neglect in institutionalized elderly. JADA 2010; 141:433-440

Geriatric Dental Experts Consensus in 2009

Time to qualify for oral neglect for 29 different oral conditions

8 days for acute conditions

35 days for chronic conditions


Tool of Operational Definition of Oral Neglect

The “validated consensus of oral neglect in institutionalized elders definition provides a utilitarian means to enforce” the legislative mandate against oral neglect.


Other Geriatric Dental experts write a response in JADA

“idea of completing timely referrals nearly impossible”

-years of declining self-care

-resident may choose not to treat dental problem

-unable to find any oral health care professional willing and available to treat their patients

Glassman, Helgeson, Fitzler, Protecting the Elderly, JADA 2010;141:1298-99.

Our research concurs

We interviewed NH administrators from across Kentucky.

“What is the biggest barrier to good oral health for your residents?”

Can’t find a dentist to treat residents

Long term staff must respect autonomy of resident

So if resident says “I don’t want to go to dentist” or “I don’t want to brush my teeth” then staff respects the wishes of the patient.

Billing for dental care in long term care

Who pays for dental services in Nursing Homes?

– Reconstructing a jaw after accident

– EXT before radiation treatment for jaw cancer

NOT MEDICARE

CMS.gov Centers for Medicare & Medicaid Services

“Medicaid covers more than 60 percent of all nursing home residents.”

Center on Budget and Policy Priorities, http://www.cbpp.org/cms/index.cfm?fa=view&id=2223

Getting paid for providing dental services for nursing homes residents

If nursing home resident is on Medicaid but Medicaid doesn’t cover the service they need, i.e. dentures, there is a way to get paid.

Incurred Medical Expense, the mechanism often used to pay for eyeglasses & hearing aids, may

also pay for necessary dental care.

Using Incurred Medical Expense

1. Patient MUST be Medicaid recipient

2. Dental service must NOT be covered by Medicaid or other third party payer

3. Patient MUST have income (SS or retirement)

http://www.ada.org/sections/professionalResources/pdfs/ime_dental_professionals.pdf

Incurred Medical ExpenseHow It Works

A resident’s monthly retirement or SS income is used to pay for medically necessary dental services instead of paying the monthly nursing home bill.

Medicaid will reimburse the facility for the money that was used to pay dentist.

IME should NOT affect balance sheet of nursing home.

ADA How-to for IME

Dentist sends bill for non-covered service to patient and to Medicaid caseworker (employee of Medicaid)


ADA How-to for IME

ADA advises including the following language on the Dental Bill when appropriate:

“This Dental Bill only includes medically necessary services that are not covered by Medicaid or any other third party payer.”


Medicaid Caseworker very important in this process

• They receive dental bill from providing dentist

• Approve payment

• Send letter to dental patient to pay bill out of monthly income

• Notify Medicaid to pay facility to make up for amount of dental bill


Documentation is Critical

The only industry that is more regulated than the nursing home

industry?

Nuclear Power

LTC facilities must undergo an annual state survey

• Can last 1 day – 1 week

• Unannounced

• All aspects of care are examined

• Sample of residents – charts are reviewed and residents interviewed

Documentation for Nursing Home

What do they need from you in terms of documentation?

To meet federal regulations:

1. Evidence that you are a dentist that provides routine and emergency dental services to meet the needs of their resident (contract/agreement)

2. Documentation of the dental services you have provided for their residents to be included in the medical chart (format? SOAP notes)

Surveyors WILL read your notes.

Surveyors want to know:

Eat okay?

Pain?

Any oral complaints?

This needs to be VISIBLE in your notes

What You Say and How You Say It

Discuss sensitive issues by phone with Director of Nursing – don’t just write a nasty note

Instead of writing “filthy teeth” write “heavy plaque present”

Instead of “poor oral care” write “needs help with oral hygiene care”

**Provide written orders for oral hygiene care.

More Documentation NeededIn Kentucky….

Facility also needs evidence that dentist

• provides consultation

• participates in-service education

• recommends policies concerning oral hygiene

• is available in case of emergency

Documentation for Dental Provider

Resident or Family Chooses Dentistat Admit

- At admittance to facility, resident or POA fills out Dental Provider Selection Form

- Essentially this is permission from the patient

for a specific dentist to see the patient

- A copy of this should be kept by facility and by facility dentist

Ethical issues/ Respecting Autonomy

What if resident doesn’t want to choose a dentist?

If patient is deemed competent, then on admittance explained that not caring for teeth could cause systemic problems but ultimately resident has the right to make a bad decision. They were making bad decisions before coming to the NH.

They choose you. Now what? What do you need from facility?

Face Sheet (first sheet in resident’s record):

demographic

Responsible Party / Power of Attorney

financial

medical diagnosis*

*DAY OF ADMIT … so medical info may be dated

What else do you need?

Physician’s orders:

Contact info of physician

Daily Medications/ Allergies

Diagnoses – may not include diagnosis that require Antibiotic prophylaxis because this is about daily orders

That’s concerning, so dentists mustspecifically ask for a current

Diagnoses / Problem List: This should list all diagnoses and problems of the patient.

Information dentists need before treating

1. Dental Provider Selection Form

2. Face Sheet

3. Physician’s Orders

4. Diagnosis/Problem Sheet

5. Consent for treatment

Patients/residents (themselves) decide about their own dental care and for which procedures they will provide consent

Except…When patients have guardians who are their Power of Attorney (POA)

Must get written Consent for Dental Procedure prior to treatment!

Face Sheet:

Demographic

Responsible Party/ Power of Attorney

Financial

May confirm with facility– Social worker

– Director of Nursing

– Administrator (Director of Facility)

How do you verify who has legal guardianship/POA in the NH setting?

No consent is needed in life threatening emergency

Working Effectively with Facility Medical Director

Should have good communication with Medical Director

• Consult with physician before invasive treatment

– Are underlying medical conditions stable?

– Necessary to alter medications?

– Are labs needed prior to procedure?

– Other issues to be considered?

Advise physician if you need to write a prescription

• Antibiotics

• Codeine for pain

• Anxiolytic drugs like Ativan

Write stop date on prescription because resident may lose weight.

Consult with Medical Director about Medications

60% of nursing home elders have xerostomia

Photos courtesy Dr. Bob Henry

Medications are the #1 cause of xerostomia

Over 400 medications cause dry mouth

- Antihypertensives

- NSAIDS

- Antidepressants

- Anti-Parkinson’s drugs

- Sleep disturbance medications

- Anti-anxiety medications

Physician may be able to alter meds to something less drying.

Drugs commonly associated with dry mouth

Working effectively with facility leadership and nursing staff

Develop a partnership with the long term facility leadership

Administrator

Director of Nursing

Social Worker

Know what is important to the leadership and nurses

Important issues:

1. Good report from surveyors

2. Avoiding pneumonia

3. Financial Concerns

How can you help solve these problems?

Lack of oral hygiene is a significant risk factor for pneumonia .

See Study by Quagliarello V et al. Modifiable risk factors for nursing home acquired pneumonia. Clin Infect Dis 2005;40:1-6.

Bacteria from plaque may be aspirated into the lungs

Photograph courtesy Dr. Robert Henry

Pneumonia is the number one cause of death in nursing homes and a significant cause of

hospitalization.

15 studies have shown brushing the teeth reduces pneumonia in nursing home residents

Brushing lowers the number of bacteria in the mouth and lowers risk of pneumonia.

Sjogren P et al. A systematic review of preventive effect of oral hygiene on pneumonia and respiratory infections in elderly people in hospitals and nursing homes. J Am Geriatr Soc 2008;56:2124-2130.

Cost savings due to fewer bed hold days because of hospitalizations

In Kentucky, Nursing Home must hold

bed 14 days if resident hospitalized.

If facility census is at least 95%, facility is reimbursed 75% of the actual per diem Medicaid rate for a bed hold day

If their census is below 95%, facility reimbursed 50% of the actual per diem Medicaid rate

http://www.ltcombudsman.org/sites/default/files/norc/state-bedhold-chart-oct2012.pdf

Can also help the leadership by providing oral health education for

nursing staff

Nursing facilities must ensure that residents receive “necessary services to maintain good nutrition, grooming

and personal and oral hygiene”

Quality of Care (483.25, Tags F310 & F312)

Citations for violating the law of oral hygiene provision are becoming more

common

More likely for NH to be cited for oral hygiene than to be cited for not having a dentist.

• Research has shown nearly 80% of long term residents need help brushing their teeth.

• But only 5% to 16% of nursing home residents receive the help they need for daily oral hygiene.

1. Frenkel HF, et al. Improving oral health in institutionalised elderly people by educating caregivers: a randomised controlled trial. Community Dent Oral Epidemiol2001;29(4):289-97.

2. Simons D, et al. Relationship between oral hygiene practices and oral status in dentate elderly people living inresidential homes. Community Dent Oral Epidemiol

2001;29(6):464-70.

3. Coleman P, Watson NM. Oral care provided by certified nursing assistants in nursing homes. J Am Geriatr Soc 2006;54(1):138-43.

Lack of needed oral hygiene assistance in nursing homes

Problems that often result in NH placement

• Impaired cognition 54.0%

• Wheelchair 50%

• Impaired Activities of daily living ADLs (dressing, feeding, transferring, toileting, bathing, grooming) 85.0% have 2 or more

• No family close by to provide caregiving

– 64.2% Widowed

– 37% No Children

1. 2006 study found only 16% of residents received any oral care (NY state, nursing assistants blinded to study focus)

2. Average toothbrushing time 16.2 seconds

3. None of nursing assistants wore clean gloves to provide oral care (often immediately after cleaning perineal area or changing soiled garments)

What about Nursing Aids? Shouldn’t they be helping?

Coleman P, Watson NM. Oral care provided by certifiednursing assistants in nursing homes. J Am Geriatr Soc

2006;54(1):138-43.

1. General lack of knowledge / low oral health literacy among staff

2. Lack of perceived need

3. Higher priorities in medical duties1. Giving meds

2. Feeding, toileting, dressing, etc.

4. Not enough nursing assistants

5. Care resistance

Barriers for nursing aids in helping with oral hygiene in nursing homes

Dentists can address these barriers by providing oral health education

sessions for staff

AKA: Dental In-Service

Does it really help?

Research shows improved oral clinical outcomes from oral health educational programs for nursing staff in long term care facilities, including improved plaque scores of residents.

• Pyle MA, Massie M, Nelson S.. A pilot study on improving oral care inlong-term care settings. Part II: Procedures and outcomes. J Gerontol Nurs 1998;24(10):35-8.• Nicol R, Petrina Sweeney M, McHugh S, Bagg J. . Effectiveness of health care worker trainingon the oral health of elderly residents

of nursing homes. Community Dent Oral Epidemiol 2005;33(2):115-24.• Peltola P, Vehkalahti MM, Simoila R. . Effects of 11-month interventions on oralcleanliness among the long-term hospitalised elderly.Gerodontology 2007;24(1):14-21.• Kullberg E, Forsell M, Wedel P, et al. A dental hygiene education for nursing staffs. Geriatr Nurs 2009;30(5):329-33.

• Support of administrators

• Small group instruction

• Hands on instruction

• Care resistance strategies

• Proper oral hygiene tools

• Importance of oral care

Successful educational programs for nursing assistants in NHs

Overcoming care-resistance

Effective communication and patient management strategies

Overcoming Care Resistance Nonverbal StrategiesApproach at right time of day – dementia AMLimit distractions and people in room (calm and quiet room)Approach from the frontGet eye levelSmileGentle touchPositive reinforcement by thumbs up or nodding yesDistract by giving something to hold

Jablonski, R. (2010) Examining oral health in nursing home residents and overcoming mouth care-resistive behaviors Annals of Long Term Care, 18, 21-26. Kayser-Jones, J., Bird, W.F., Redford, M. (1996). Strategies for conducting dental examinations among cognitively impaired nursing home residents. Special Care Dentist 16, 46-52.

Overcoming Care Resistance

Verbal Strategies

Warm greeting

Identify who you are / what you are going to do

Pay a compliment

Deliver one thought at a time

Short simple commands “Open please”

Avoid elderspeak – patronizing babytalk

Jablonski, R. (2010) Examining oral health in nursing home residents and overcoming mouth care-resistive behaviors Annals of Long Term Care, 18, 21-26. Kayser-Jones, J., Bird, W.F., Redford, M. (1996). Strategies for conducting dental examinations among cognitively impaired nursing home residents. Special Care Dentist 16, 46-52.

Utilize Implicit Memory in Dementia Patients

Have patient hold toothbrush then with your hand over the patient’s hand move the toothbrush over the teeth. This may help them remember how to brush.

Pantomime may help

You show and act out. Whenever possible demonstrate what you want the person to do. Show them what you mean by brushing.

What if patient is angry and refuses care?

Don’t force it.

Try again later when the patient may feel better

Central Supply Director orders supplies and is given a budget

• Cheap, large headed, hard bristled toothbrushes.

• Cheap toothpaste -tastes bad

• Mouthwash that has no therapeutic value

Lack of quality oral hygiene supplies is an issue

Photo courtesy Dr. Bob Henry

CARE RESISTANCE!!

Foam swabs: are okay for swabbing mucosa but NOT effective in removing plaque from teeth

May be impregnated with lemon and glycerin –harsh, acidic and dehydrating

Nurses and facilities often choose…

• CDC recommends:

After oral care, the toothbrush/denture brush should be rinsed well and place in the driest cleanest place in room

Storing Oral Hygiene Tools also an issue

• Talk to leadership, residents, families and Activities Director about appropriate supplies.

• Each resident has $40 per month to buy personal items and Activity Director goes shopping for resident or with resident.

Dentist Should Advocate for Better Oral Hygiene Tools

The Collis Curve Toothbrush may make toothbrushing easier and quicker. This brush has three layers of bristles and brushes all 3

sides of teeth at one time.

• Support of administrators

• Small group instruction

• Hands on instruction

• Care resistance strategies

• Proper oral hygiene tools

• Importance of oral care

Successful educational programs for nursing assistants in NHs

Communicating Importance of Oral Care to Staff

Wound Care

resonates with staff and leadership

Wound Animation

Safety Concerns regarding providing oral hygiene for nursing home

residents.

Do NOT use toothpaste, mouthwash or water for the following patients

• Comatose patients

• Patients with swallowing problem (dysphagia) on a restricted diet of thickened liquids that can’t have thin liquids (30-40% dysphagia)

• Care resistant patients

• Patients who hold liquids in mouth/ can’t or won’t spit but instead swallow liquids placed in mouth

22 of 59

How to provide oral care without toothpaste, mouthwash or water?

• Simply moisten a toothbrush with a very small amount of water or mouthwash and brush teeth as normal.

• If possible floss teeth

• After brushing and flossing wipe the mouth out with a toothette or gauze moistened with mouthwash.

If possible, patient should be

sitting up for oral care.

Lying back for oral care is an aspiration risk

If patient can’t get out of bed, elevate head of bed.

“After you have washed your hands and put on gloves, DO NOT touch anything (except your patient’s own oral hygiene supplies) before providing oral care. Touching other things will get germs on your gloves that will go into your patient’s mouth and could make them sick.”

Emphasize infection control!!!

Free resources provided for dental professionalshttp://www.uky.edu/NursingHomeOralHealth/

Funded by Dental Trade Alliance Foundation

Another Website with Free Resources http://www.ahprc.dal.ca/projects/oral-care/

Another Website with Free Resources http://pdhaonline.org/?page_id=188.

Thank You!

Inside every senior is a 23 year old wondering what the heck happened!

Documents

Expanding your Dental Practice to Meet the Oral Health ... · patient to be transported to the dentist's office. SAME AS FEDERAL 3. An advisory dentist shall provide consultation,